FHIR IG analytics| Package | tw.cohesion.fhir.clinemr |
| Resource Type | Composition |
| Id | Composition-CompositionDCR-min.json |
| FHIR Version | R4 |
No resources found
No resources found
Note: links and images are rebased to the (stated) source
病歷表單版本：2
臨床狀態：Final (CompositionStatus#final)
種類：Outpatient Note ( LOINC#34108-1)
病人：Patient/PatientDCR-min "王童"
就醫事件：Encounter/EncounterDCR-min
文件產生時間：2023-09-10T10:30:00
醫事機構代碼：OrganizationDCR-min "3214567890"
醫事機構名稱：OrganizationDCR-min "捷達世牙醫診所"
文件標題：牙醫門診單
文件敏感性：normal ( v3 Code System Confidentiality#N)
病摘小節內容：
section[PatientInformation]：
section[educationlevel]： Observation/ObservationEducationLevelDCR-min
section[occupation]： Observation/ObservationOccupationDCR-min
section[bloodtype]： Observation/ObservationBloodtypeDCR-minsection[AllergyIntolerance]： Allergyintolerance/AllergyIntoleranceDCR-min
section[ConditionPastMedicalHistory]： Condition/ConditionPastMedicalHistoryDCR-min
section[ConditionMajorIllness]： Observation/ObservationMajorIllnessDCR-min
section[ConditionMajorIllness]： Condition/ConditionMajorIllnessDCR-min
section[ConditionMajorIllness]： Condition/ConditionMajorIllnessDCR-prosection[Medication]：
section[medication]： Medication/MedicationDCR-min
section[medication]： Medication/MedicationDCR-pro
section[medicationrequest]： MedicationRequest/MedicationRequestDCR-min
section[medicationrequest]： MedicationRequest/MedicationRequestDCR-prosection[ConditionDiagnosis]：
section[conditiondiagnosis]： Condition/ConditionDiagnosisDCR-min
section[practitioner]： Practitioner/PractitionerClinEMR-min
section[careplan]： CarePlan/CarePlanDCR-minsection[ConditionChiefComplaint]： Condition/ConditionChiefComplaintDCR-min
section[ObservationVitalSign]： Observation/ObservationVitalSignDCR-min
section[Procedure]： Procedure/ProcedureDCR-min
section[ObservationLabResults]：
section[observation]： Observation/ObservationDCR-min
section[servicerequest]： ServiceRequest/ServiceRequestDCR-min
section[diagnosticreport]： DiagnosticReport/DiagnosticReportDCR-min
section[organizationinspection]： Organization/OrganizationInspectionClinEMR-minsection[DocumentReference]： DocumentReference/DocumentReferenceDCR-min
FHIR
FHIRsmith{
"resourceType": "Composition",
"id": "CompositionDCR-min",
"meta": {
"versionId": "2",
"profile": [
"https://fhir.cohesiondata.com/clinemr/StructureDefinition/composition-dcr"
]
},
"text": {
"status": "generated",
"div": "<!-- snip (see above) -->"
},
"identifier": {
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "SNO"
}
]
},
"value": "TW.Foxconn.Clinic.Dental.1"
},
"status": "final",
"type": {
"coding": [
{
"system": "http://loinc.org",
"code": "34108-1",
"display": "Outpatient Note"
}
]
},
"subject": {
"reference": "Patient/PatientDCR-min"
},
"encounter": {
"reference": "Encounter/EncounterDCR-min"
},
"date": "2010-04-21T14:30:00+08:00",
"author": [
{
"reference": "Organization/OrganizationDCR-min"
}
],
"title": "牙醫門診單",
"confidentiality": "N",
"section": [
{
"title": "病人資料",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "52460-3",
"display": "Patient Information"
}
]
},
"section": [
{
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "80913-7",
"display": "Highest level of education [US Standard Certificate of Death]"
}
]
},
"entry": [
{
"reference": "Observation/ObservationEducationLevelDCR-min"
}
]
},
{
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "85658-3",
"display": "Occupation [Type]"
}
]
},
"entry": [
{
"reference": "Observation/ObservationOccupationDCR-min"
}
]
},
{
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "882-1",
"display": "ABO and Rh group [Type] in Blood"
}
]
},
"entry": [
{
"reference": "Observation/ObservationBloodtypeDCR-min"
}
]
}
]
},
{
"title": "過敏史",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "48765-2",
"display": "Allergies and adverse reactions Document"
}
]
},
"entry": [
{
"reference": "AllergyIntolerance/AllergyIntoleranceDCR-min"
}
]
},
{
"title": "過去病史",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "11348-0",
"display": "History of Past illness Narrative"
}
]
},
"entry": [
{
"reference": "Condition/ConditionPastMedicalHistoryDCR-min"
}
]
},
{
"title": "重大傷病",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "11338-1",
"display": "History of Major illnesses and injuries Narrative"
}
]
},
"entry": [
{
"reference": "Observation/ObservationMajorIllnessDCR-min"
}
],
"section": [
{
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "11338-1",
"display": "History of Major illnesses and injuries Narrative"
}
]
},
"entry": [
{
"reference": "Condition/ConditionMajorIllnessDCR-min"
}
]
},
{
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "11338-1",
"display": "History of Major illnesses and injuries Narrative"
}
]
},
"entry": [
{
"reference": "Condition/ConditionMajorIllnessDCR-pro"
}
]
}
]
},
{
"title": "用藥紀錄",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "10160-0",
"display": "History of Medication use Narrative"
}
]
},
"section": [
{
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "87232-5",
"display": "Medication administration.brief"
}
]
},
"entry": [
{
"reference": "Medication/MedicationDCR-min"
}
]
},
{
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "87232-5",
"display": "Medication administration.brief"
}
]
},
"entry": [
{
"reference": "Medication/MedicationDCR-pro"
}
]
},
{
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "57833-6",
"display": "Prescription for medication"
}
]
},
"entry": [
{
"reference": "MedicationRequest/MedicationRequestDCR-min"
}
]
},
{
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "57833-6",
"display": "Prescription for medication"
}
]
},
"entry": [
{
"reference": "MedicationRequest/MedicationRequestDCR-pro"
}
]
}
]
},
{
"title": "診斷",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "11450-4",
"display": "Problem list - Reported"
}
]
},
"section": [
{
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "29548-5",
"display": "Diagnosis Narrative"
}
]
},
"entry": [
{
"reference": "Condition/ConditionDiagnosisDCR-min"
}
]
},
{
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "18600-7",
"display": "Primary practitioner identifier"
}
]
},
"entry": [
{
"reference": "Practitioner/PractitionerClinEMR-min"
}
]
},
{
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "101541-1",
"display": "Multidisciplinary Comprehensive plan of care note"
}
]
},
"entry": [
{
"reference": "CarePlan/CarePlanDCR-min"
}
]
}
]
},
{
"title": "病人主訴",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "10154-3",
"display": "Chief complaint Narrative - Reported"
}
]
},
"entry": [
{
"reference": "Condition/ConditionChiefComplaintDCR-min"
}
]
},
{
"title": "生命徵象",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "8716-3",
"display": "Vital signs"
}
]
},
"entry": [
{
"reference": "Observation/ObservationVitalSignDCR-min"
}
]
},
{
"title": "處置或手術",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "29554-3",
"display": "Procedure Narrative"
}
]
},
"entry": [
{
"reference": "Procedure/ProcedureDCR-min"
},
{
"reference": "Procedure/ProcedureDCR-pro"
}
]
},
{
"title": "實驗室檢驗檢查紀錄",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "30954-2",
"display": "Relevant diagnostic tests/laboratory data Narrative"
}
]
},
"section": [
{
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "19146-0",
"display": "Referral lab test results"
}
]
},
"entry": [
{
"reference": "Observation/ObservationDCR-min"
}
]
},
{
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "77597-3",
"display": "Orders placed Document"
}
]
},
"entry": [
{
"reference": "ServiceRequest/ServiceRequestDCR-min"
}
]
},
{
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "50398-7",
"display": "Narrative diagnostic report [Interpretation]"
}
]
},
"entry": [
{
"reference": "DiagnosticReport/DiagnosticReportDCR-min"
}
]
},
{
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "52482-7",
"display": "Laboratory"
}
]
},
"entry": [
{
"reference": "Organization/OrganizationInspectionClinEMR-min"
}
]
}
]
},
{
"title": "健康問題文件",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "75310-3",
"display": "Health concerns Document"
}
]
},
"entry": [
{
"reference": "DocumentReference/DocumentReferenceDCR-min"
}
]
}
]
}